1. The patient is a 70-year-old Thai man who fell at his home 1 day ago and was brought to the hospital. 2. On examination, he had a sutured head wound and swelling and pain in his right ankle that prevented walking. 3. X-rays showed a closed bimalleolar fracture of the right ankle. He was admitted for pain control, immobilization, and pre-operative management.

1. EXTERN CONFERENCE
EXT. POLLACHAT SUKSANGDOW

2. PATIENT PROFILE
▪ ผู้ป่วยชายไทยอายุ 70 ปี
▪ ภูมิลาเนา จ.นครราชสีมา
▪ สัญชาติไทย นับถือศาสนาพุทธ
▪ สิทธิการรักษา บัตรทองผู้สูงอายุ
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3. CHIEF COMPLANT
▪ ปวดข้อเท้าขวา 1 วันก่อนมาโรงพยาบาล
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4. PRESENT ILLNESS
▪ 1 วันก่อนมาโรงพยาบาล ญาติพบผู้ป่วยล้มอยู่ในบ้านบริเวณโถงบ้าน ศีรษะ
กระแทกพื้น มีแผลที่ฉีกขาดด้านหลังศีรษะ มีเจ็บบริเวณข้อเท้าข้างขวาบวม
ปวดมาก ผู้ป่วยไม่สามารถเดินลงน้าหนักได้ จึงมาโรงพยาบาล
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5. PRIMARY SURVEY MNRH
▪ A: Can speak, C-spine not tender
▪ B: Clear both lung, Equal breath sound
▪ C: BP HR no active bleeding
▪ D: E4V5M6, pupil 3 mm. RTLBE, motor IV+ all Extremities
▪ E: Sutured wound at Left side of Head ~ 3 cm.
Swelling at Left ankle, no external wound, no ecchimosis
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6. SECONDARY SURVEY MNRH
▪ A: no hx of drug or food Allergy
▪ M: Simvastatin, ASA
▪ P: Old CVA
▪ L: 9.00 น.
▪ E: Falling 1 day PTA ญาติพบผู้ป่วยนั่งอยู่บนพื้นบ้านมี ลุกไม่ได้มีอาการปวด
บวมบริเวณข้อเท้าขวา
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7. PHYSICAL EXAMINATION
▪ V/S : BP HR RR 20 T
▪ HEENT : not pale, no jaundice
▪ Heart : normal, S1 S2, no murmur
▪ Lung : clear both lungs
▪ Abdomen : not distend, soft, not tender
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8. PHYSICAL EXAMINATION
▪ Extremities
Rt. Ankle Swelling, Mark tender medial malleolus area, Mild
tender lateral malleolus area, Limit ROM due to pain, normal
pinprick sensation, cap.refill < 2 sec, DPA, PTA 2+
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9. ADJUNCTS to SECONDARY SURVEY
▪ Film : Rt. Ankle AP, LAT, Mortise
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10. AP
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11. LAT
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12. Mortise
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13. IMPRESSION
▪ Closed fracture bimalleolar of Right Ankle
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14. MANAGEMENT
▪ Pain Control
▪ Immobilization : Posterior Short Leg Slab
▪ Admit
▪ Pre-operative
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15. Ankle Fracture

16. Anatomy
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17. CAUSE
▪ TWIST or Rotating of Ankle
▪ Falling
▪ Impact Force
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18. Clinical Presentation
▪ Pain
▪ Swelling
▪ Bruise / Ecchymosis
▪ Tender on palpation
▪ Can’t weight bearing
▪ Deformity
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19. 19

20. Mechanism
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Lauge-Hansen Class Sequence
Supination - Adduction
(SA)
1.Talofibular sprain or distal fibular avulsion
2.Vertical medial malleolus and impaction of anteromedial distal tibia
Supination - External
Rotation (SER)
1.Anterior tibiofibular ligament sprain
2.Lateral short oblique fibula fracture (anteroinferior to posterosuperior)
3.Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
4.Medial malleolus transverse fracture or disruption of deltoid ligament
Pronation - Abduction
(PA)
1.Medial malleolus transverse fracture or disruption of deltoid ligament
2.Anterior tibiofibular ligament sprain
3.Transverse comminuted fracture of the fibula above the level of the
Syndesmosis
Pronation - External
Rotation (PER)
1.Medial malleolus transverse fracture or disruption of deltoid ligament
2.Anterior tibiofibular ligament disruption
3.Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior)
above the level of the joint
4.Posterior tibiofibular ligament rupture or avulsion of posterior malleolus

21. 21

22. 22

23. 23

24. 24

25. Classification
▪ Anatomic / Descriptive
▫ isolated medial malleolar
▫ isolated lateral malleolar
▫ bimalleolar
▫ trimalleolar
▫ Bosworth fracture-dislocation (posterior dislocation of the fibula
behind incisura fibularis)
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26. Classification
▪ Danis-Weber (location of fibular fracture)
▫ A - infrasyndesmotic (generally not associated with
ankle instability)
▫ B - transsyndesmotic
▫ C - suprasyndesmotic
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27. 27

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30. 30

31. Investigation
▪ Plain Film
▫ AP
▫ LAT
▫ Mortise
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32. Measurement
▪ Talocrural angle
8-15 o.
Smaller is
fibular shortening.
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33. Measurement
▪ Tibiofibular
shortening,
rotation
lateral displacement
of the fibula.
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34. Measurement
▪ Talar tilt
2 mm.
not parallel
instability of
the ankle joint.
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35. Measurement
▪ Medial clear space
▫ lateral shift of the talus
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36. Measurement
▪ Syndesmotic injury
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37. Treatment
▪ Non-operative
▫ short-leg walking cast/boot
indications
▫ isolated nondisplaced medial malleolus fracture or tip avulsions
▫ isolated lateral malleolus fracture with < 3mm displacement
and no talar shift
▫ bimalleolar fracture if elderly or unable to undergo surgical intervention
▫ posterior malleolar fracture with < 25% joint involvement
or < 2mm step-off
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38. Treatment
▪ Operative
▫ open reduction internal fixation
▪ indications
▫ any talar displacement
▫ displaced isolated medial malleolar fracture
▫ displaced isolated lateral malleolar fracture
▫ bimalleolar fracture and bimalleolar-equivalent fracture
▫ posterior malleolar fracture with > 25% or > 2mm step-off q
▫ Bosworth fracture-dislocations, Syndesmotic Injury
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39. COMPLICATION
▪ Infection
▪ Post-Traumatic Arthritis
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40. THANK YOU
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